A nurse is assessing a client who has suspected appendicitis. Which of the following
manifestations should the nurse expect? - ANSWER Elevated WBC Count
Rebound Tenderness
Anorexia
A nurse is caring for a client immediately following intubation with an endotracheal
(ET) tube. Which of the following methods should the nurse identify as the most
reliable for verifying placement of the ET tube? - ANSWER Check for end-tidal
carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube
placement is checking for end-tidal carbon dioxide levels by using capnometry. A
chest x-ray is another reliable method for verifying placement.
A nurse is planning care for a. client who has a lump in their right breast. Which of
the following findings increases the client's risk of developing breast cancer? -
ANSWER Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen.
Higher levels of estrogen in the body increase the risk for postmenopausal breast
cancer.
A nurse is providing discharge teaching to a client following a loop electrosurgical
excision procedure (LEEP) for the treatment of cervical cancer. Which of the
following statements by the client indicates an understanding of the teaching? -
ANSWER "I may have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which is
performed in ambulatory care using a painless electrical current.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The
nurse should identify which of the following findings as an indication of a
microvascular complication? - ANSWER Retinopathy
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting
from pathologic changes in small blood vessels, which eventually cause tissue
damage, cell death in the retina, and blindness.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat
, stroke. Which of the following actions should the nurse take first? - ANSWER
Administer oxygen using a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and
circulation approach to client care is to ensure that the client has a patent airway and
administer oxygen using a high-concentration mask to promote oxygen perfusion to
vital organs.
A nurse notes that a client's eyes are protruding slightly from their orbits. Which of
the following laboratory findings should the nurse expect? - ANSWER Increased T4
levels
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of
hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased
thyroid stimulating hormone level reflect primary hyperthyroidism.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which
of the following mechanisms should the nurse identify as responsible for this acid-
base imbalance? - ANSWER Retention of carbon dioxide
Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon
dioxide can result from respiratory depression, inadequate chest expansion, airway
obstruction, or decreased alveolar capillary diffusion.
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of
hypovolemia. Which. Of the following findings should the nurse identify as a
manifestation of hypovolemia? - ANSWER Rapid pulse rate
A client who has hypovolemia has a rapid, weak pulse rate to compensate for the
decrease in blood volume in an attempt to increase blood pressure.
A nurse is providing teaching for a client who has constipation-predominant irritable
bowel syndrome (IBS-C). Which of the following statements should the nurse include
in the teaching? - ANSWER "Take psyllium in the evening."
A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to
increase the bulk of the stool, reduce constipation, and promote regular bowel
movements.
manifestations should the nurse expect? - ANSWER Elevated WBC Count
Rebound Tenderness
Anorexia
A nurse is caring for a client immediately following intubation with an endotracheal
(ET) tube. Which of the following methods should the nurse identify as the most
reliable for verifying placement of the ET tube? - ANSWER Check for end-tidal
carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube
placement is checking for end-tidal carbon dioxide levels by using capnometry. A
chest x-ray is another reliable method for verifying placement.
A nurse is planning care for a. client who has a lump in their right breast. Which of
the following findings increases the client's risk of developing breast cancer? -
ANSWER Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen.
Higher levels of estrogen in the body increase the risk for postmenopausal breast
cancer.
A nurse is providing discharge teaching to a client following a loop electrosurgical
excision procedure (LEEP) for the treatment of cervical cancer. Which of the
following statements by the client indicates an understanding of the teaching? -
ANSWER "I may have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which is
performed in ambulatory care using a painless electrical current.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The
nurse should identify which of the following findings as an indication of a
microvascular complication? - ANSWER Retinopathy
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting
from pathologic changes in small blood vessels, which eventually cause tissue
damage, cell death in the retina, and blindness.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat
, stroke. Which of the following actions should the nurse take first? - ANSWER
Administer oxygen using a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and
circulation approach to client care is to ensure that the client has a patent airway and
administer oxygen using a high-concentration mask to promote oxygen perfusion to
vital organs.
A nurse notes that a client's eyes are protruding slightly from their orbits. Which of
the following laboratory findings should the nurse expect? - ANSWER Increased T4
levels
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of
hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased
thyroid stimulating hormone level reflect primary hyperthyroidism.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which
of the following mechanisms should the nurse identify as responsible for this acid-
base imbalance? - ANSWER Retention of carbon dioxide
Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon
dioxide can result from respiratory depression, inadequate chest expansion, airway
obstruction, or decreased alveolar capillary diffusion.
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of
hypovolemia. Which. Of the following findings should the nurse identify as a
manifestation of hypovolemia? - ANSWER Rapid pulse rate
A client who has hypovolemia has a rapid, weak pulse rate to compensate for the
decrease in blood volume in an attempt to increase blood pressure.
A nurse is providing teaching for a client who has constipation-predominant irritable
bowel syndrome (IBS-C). Which of the following statements should the nurse include
in the teaching? - ANSWER "Take psyllium in the evening."
A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to
increase the bulk of the stool, reduce constipation, and promote regular bowel
movements.
